UNASSIGNED: An ESPGHAN position paper on the diagnosis, management and prevention of cow\'s milk allergy RELEASE DATE: Journal of Pediatric Gastroenterology and Nutrition, July 26, 2023 PRIOR VERSION: 2012 DEVELOPER: ESPGHAN (European Society of Paediatric Gastroenterology, Hepatology and Nutrition), NASPGHAN (North American Society of Pediatric Gastroenterology, Hepatology and Nutrition) FUNDING SOURCE: ESPGHAN TARGET POPULATION: Infants and young children with suspected cow\'s milk allergy.

Cow\'s milk allergy (CMA) is one of the most common food allergies world-wide. The emergence of online CMA symptom questionnaires, aimed at parents and/or healthcare professionals (HCP), may raise awareness about the possible diagnosis of CMA, but also increases the risk for overdiagnosis leading to unnecessary dietary restriction impacting on growth and nutrition. This publication sets out to establish the availability of these CMA symptom questionnaires and critically assesses the development and validity.
Thirteen HCP working in the field of CMA, from different countries, were recruited to participate. A combination of a Pubmed and CINAHL literature and online review using the Google search engine in English language was used. Symptoms in the questionnaires were assessed, using the European Academy for Allergy and Clinical Immunology guidelines for food allergy. Following the assessment of both the questionnaires and literature, the authors followed the modified Delphi approach to generate consensus statements.
Six hundred and fifty-one publications were identified, of which 29 were suitable for inclusion, with 26 being associated with the Cow\'s Milk-Related Symptoms Score. The online search yielded 10 available questionnaires: 7/10 were sponsored by formula milk companies and 7/10 were aimed at parents and three at HCP. Following the assessment of data, 19 statements were generated in two rounds of anonymous voting reaching 100% agreement.
Online CMA questionnaires, available to parents and HCP\'s, are varied in symptoms, and most were not validated. The overarching consensus generated from authors is that these questionnaires should not be used without the involvement of HCP.

The transition of foods during toddlerhood and the suboptimal diets consumed in the Middle East make children susceptible to malnutrition and micronutrient deficiencies. Based on international recommendations, coupled with the merits of clinical studies on the application of young child formula (YCF), a group of fourteen experts from the Middle East reached a consensus on improving the nutritional status of toddlers. The recommendations put forth by the expert panel comprised twelve statements related to the relevance of YCF in young children; the impact of YCF on their nutritional parameters and functional outcomes; characteristics of the currently available YCF and its ideal composition; strategies to supply adequate nutrition in young children and educational needs of parents and healthcare professionals (HCPs). This consensus aims to serve as a guide to HCPs and parents, focusing on improving the nutritional balance in toddlers in the Middle Eastern region. The panellists considere YCF to be one of the potential solutions to improve the nutritional status of young children in the region. Other strategies to improve the nutritional status of young children include fortified cow\'s milk and cereals, vitamin and mineral supplements, early introduction of meat and fish, and the inclusion of diverse foods in children\'s diets.

Non-IgE-mediated Cow\'s Milk Allergy (CMA) has a prevalence of less than 1% in children. Guidelines developed to help non-specialists diagnose CMA may lead to misattribution of normal symptoms and contribute to overdiagnosis of CMA. We sought to establish the frequency of symptoms during infancy associated with non-IgE-mediated CMA, using the international Milk Allergy in Primary Care (iMAP) guideline as representative of CMA guidelines more generally.
Secondary analysis of the Enquiring About Tolerance (EAT) randomized controlled trial (ISRCTN 14254740; 1303 exclusively breastfed 3-month-old healthy infants). Key outcomes were ≥2 iMAP symptoms associated with \'mild-moderate\' and \'severe\' non-IgE-mediated CMA.
Whilst breastfeeding and parental atopy rates were higher than the general population, participants were otherwise similar to the population of England and Wales. Two or more non-IgE CMA symptoms were reported by 25% families for mild-moderate and 1.4% for severe symptoms each month between ages 3 and 12 months, peaking at 38% with ≥2 mild-moderate and 4.3% ≥2 severe symptoms at three months, when participants were not directly consuming cow\'s milk. 74% of participants reported ≥2 mild-moderate symptoms and 9% ≥2 severe symptoms in at least one month during this period. At six months there was no evidence of difference in the proportion of children with ≥2 symptoms between those consuming (29.5% mild-moderate, 1.8% severe) and not consuming cow\'s milk (35.3% mild-moderate, 2.2% severe). Mean monthly reporting of ≥2 symptoms was also no different between those with (15.8% mild-moderate, 1.1% severe) or without eczema at baseline (16.7% mild-moderate, 1.3% severe).
Guideline-defined symptoms of non-IgE-mediated CMA are very common in infants. Guidelines may promote milk allergy overdiagnosis by labelling normal infant symptoms as possible milk allergy.

Appetitive traits influence food intake and weight gain throughout the life-course. Here, we investigated whether maternal attitudes to following healthy infant feeding guidelines could modify this association. Baseline data from 544 mother-infant formula-feeding dyads recruited to the Baby Milk Trial were included in this observational, cross-sectional analysis. Infant appetitive traits (food responsiveness and satiety responsiveness), maternal attitudes to following healthy infant feeding guidelines (self-efficacy, outcome-expectancy, intentions) and infant milk intakes were reported by mothers through questionnaires. Infant weight was measured using standard procedures. Associations between the maternal attitudes score or infant appetitive traits with infant milk intake and infant weight were evaluated in linear regression models adjusted for infant sex and age. To identify effect modification, the interaction term between the maternal attitudes score and infant appetitive trait was added to the model. Infants\' mean age and weight were 2.3 months (SD = 0.9) and 5.5 kg (SD = 0.9), respectively. The mean daily infant milk intake reported by mothers was 895 ml/day (SD = 215). Higher maternal attitudes score was associated with lower infant milk intake (Beta = -68.4 ml/day/unit (95% CI: 96.6, -40.2)) and infant weight (Beta = -0.13 SD/unit (-0.25, -0.02)). The maternal attitudes score showed interactions with infant food responsiveness on infant milk intake (p = 0.049), and with infant satiety responsiveness on infant weight (p = 0.01). In both cases, a higher maternal attitudes score attenuated the associations between infant appetitive traits and those outcomes. This analysis provides evidence that positive maternal attitudes to following healthy infant feeding guidelines attenuate the effects of infant appetitive traits on infant milk intake and body weight.

To estimate the prevalence of frequent milk consumption (≥five times/week), the consumption of low-fat/skimmed milk and associated factors in adults and older people, evaluating adherence to current Brazilian guideline.
Population-based cross-sectional study involving the analysis of data from the 2015 Campinas Food Intake and Nutritional Status and 2015 Campinas Health Survey. The prevalence of milk consumption was analysed according to socio-economic characteristics, morbidities and health-related behaviours.
City of Campinas, state of São Paulo, Brazil.
A sample of 1710 participants of the 2015 Campinas Nutritional and Health Surveys.
A total of 73·8 % of the population consumed milk, but the prevalence of frequent consumption was only 44·0 %. Frequent milk consumption was higher among women, older people and individuals with better diet quality. A total of 18·4 % of the individuals who consumed milk reported consuming low-fat/skimmed milk; this prevalence was higher among women, individuals with a higher socio-economic status, those with better diet quality and those with chronic diseases.
Despite the high nutritional quality of milk and the different types available on the market, adults and older people do not follow current recommendations regarding its consumption. Information on the nutritional quality of milk and current recommendations should be disseminated more at healthcare services.

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A landmark 2015 trial on early exposure to peanuts led to expert recommendations for screening and early peanut introduction in high-risk (severe eczema and/or egg allergy) infants, but the impact of this paradigm shift on allergy testing and diagnosis is unknown.
We assessed the effects of the Learning Early About Peanut Allergy (LEAP) trial and guideline publications on allergy testing and food allergy diagnoses in infants.
In this retrospective cohort study, deidentified administrative health claims from a commercial and Medicare advantage claims database were used. Infants with at least 1 year of continuous coverage were selected using newborn codes for birth hospitalizations from January 2010 to June 2018. Interrupted time series models were used to compare the prevalence of allergy testing before and after LEAP publication in February 2015 and formal guideline publication in January 2017.
For 487,533 included infants, allergy testing increased after LEAP (risk ratio [RR]: 1.11 [95% confidence interval (CI), 1.07-1.15]) and guidelines (1.21 [1.18-1.23]). This increase of testing was also seen in infants not considered high risk, both after LEAP (1.12 [1.08-1.17]) and guidelines (1.20 [1.16, 1.23]). For first-time allergy tests, post-guideline median number of allergens tested was 9 for serum tests and 10 for skin tests. Post-guidelines, there was a significant increase in diagnosis of peanut (RR: 1.08 [1.00, 1.16]), egg (1.12 [1.05, 1.20]), and other food allergies (excluding milk) (1.22 [1.14, 1.31]).
Allergy testing has increased, including in non-high-risk infants. Multiallergen testing may be contributing to an increase in the diagnosis of other food allergies.

Recent Healthy Drinks, Healthy Kids (HDHK) guidelines state children between 12 and 24 months need to be consuming 2-3 cups a day of whole fat cow\'s milk, and less of all other beverages except water. Guidelines explicitly state plant-based milks should be avoided (with the exception of soy milk). We agree that in the first 12 months the optimal food for childhood growth is breast milk, with formula used where needed. However, after weaning, milk of any kind is not required, and should not be relied upon as a main source of calories. Children will be fine with water and a healthy balanced diet. Whether cow\'s milk should be consumed is beyond our scope here, however it is clear that plant-based milks can easily be included in day-to-day use post-weaning. Used in this fashion plant-based milks can be less harmful than dairy milks; at least for certain groups. Although cow\'s milk is rich in calcium, it does not appear to clearly reduce fractures, but consumption carries risks including: a potential association with type 1 diabetes mellitus onset; anemia in toddlers; lactose intolerance; cow\'s milk protein allergy; and infantile colic. Adverse effects from normal consumption must be compared against risks from plant-based milks, which are problematic mainly when used inappropriately in otherwise unbalanced diets; e.g. with inadequate solid foods. Despite limited evidence of serious harms from consumption of plant-based milks, HDHK provides vigorous recommendations, especially by comparison to guidelines with more evidence to support their stance (such as processed meats causing colorectal cancer).